- NEW! Successful Reduction of Polypharmacy in Children and Adolescents
- Presence of post-concussion syndrome symptoms in patients with chronic pain vs mild traumatic brain injury
- Assessment and treatment of apathy syndrome following head injury
- Clozapine impact on clinical outcomes and aggression in severely ill adolescents with childhood-onset schizophrenia
- Safety and Efficacy of ECT in Patients with Head Injury: A Case Series
- Treatment of aggression and irritability after head injury
- Prevalence of apathy following head injury
- Tc-HMPAO SPECT in persistent post-concussion syndrome after mild head injury: comparison with MRI/CT
- Antidepressant efficacy and cardiovascular safety of venlafaxine in young vs old patients with comorbid medical disorders
- Clinical utility of clozapine in 16 patients with neurological disease
- Hemiballismus following closed head injury
- Obsessive-compulsive disorder after closed head injury: review of literature and report of four cases
- ECT as a therapeutic option in severe brain injury
- Anterior cervical debridement and strut-grafting for osteomyelitis of the cervical spine
- Outcome of laminectomy for civilian gunshot injuries of the terminal spinal cord and cauda equina: review of 88 cases
- Treatment of Apathy Syndrome After Acquired Brain Injury - A Case Series
- Impact of Clozapine on Clinical Outcomes and Aggression in Severely ill in-Patients with Childhood Onset Schizophrenia
- Head Injuries in Children (Letter published in Post Gazette, Pittsburgh, PA)
- Post Concussion Syndrome - A Neuropsychiatric Perspective
- Prevalence of apathy following head injury
- Apathy secondary to neurologic disease
- Apathy syndrome after head injury and treatment outcomes
patients with chronic pain vs. mild traumatic brain injury.
DESIGN: Group comparison between patients with CP and MTBI on the Rivermead Post-Concussion Questionnaire (RPCQ). METHODS: Sixty-three patients with CP and 32 with MTBI were evaluated at the authors' institutions. Patients completed the RPCQ as part of their initial evaluation.
RESULTS: No group differences were found for total RPCQ scores. There were some differences in the proportion of patients endorsing specific symptoms. However, most people with CP endorsed symptoms consistent with PCS.
CONCLUSIONS: PCS symptoms are not unique to MTBI, and may be seen in conditions such as CP.
Brain Injury 2003 Mar;17(3):199-206.
OBJECTIVE: To evaluate the impact of clozapine on aggressive behaviour and clinical outcomes in children and adolescents with schizophrenia or schizoaffective disorder.
METHODS: We reviewed the charts of 6 children and adolescents who were admitted consecutively to a long-term care facility for clinical outcomes, including seclusion and restraints incidents prior to and during clozapine treatment. We also present a representative case history.
RESULTS: We noted clinically significant improvements in social interaction and decreases in the number of violent episodes and homicidal or suicidal thoughts. The global assessment of functioning (GAF) scores improved significantly. Weight gain was significant.
CONCLUSIONS: These cases illustrate the benefits of clozapine treatment in refractory childhood-onset schizophrenia. Outcomes are similar to those described in adults. Even though open data limit conclusions from this study, it is pertinent that there was a clinically significant improvement in aggressive behaviours. This may be particularly important for improved morale of patients, their families, and treating staff. It may also be helpful in discharge to a less restrictive environment.
Can J Psychiatry. 2001 Dec;46(10):965-8
J Neuropsychiatry Clin Neurosci 11:32-37, February 1999
Brain Injury. 1998 Aug;12(8):661-6.
Brain Injury. 1998 Jan;12(1):87-92.
Brain Injury. 1997 Feb;11(2):115-24.
RESULTS: Sixteen nongeriatric patients (age, 13 to 56 years) were compared with eighteen elderly patients (age, 65 to 86 years). Most patients (88%) had serious medical comorbidities or histories. Despite a higher mean daily venlafaxine dosage for patients in the young group, no significant changes in systolic blood pressure were noted in either group. For the older group, we found a non-statistically significant 4.7 mm Hg mean increase in diastolic blood pressure. No patient became hypertensive. We also found a negative correlation between baseline diastolic blood pressure and change in diastolic blood pressure during treatment with venlafaxine. This inverse relationship was statistically significant in the older patients.
CONCLUSIONS: Venlafaxine was not associated with significant, sustained changes in blood pressure in any patient receiving dosages of 50-250 mg/day. Minimal changes in diastolic blood pressure were no more likely to occur in older venlafaxine-treated patients than in younger ones. Higher baseline diastolic blood pressure in older patients, but not in younger ones, seemed to protect against diastolic adrenergic blood pressure effects of venlafaxine.
Int. J Psychiatry Med. 1997;27(4):353-64.
J Neuropsychiatry Clin Neurosci 1996; 8:92-96
Brain Injury. 1996 Feb;10(2):155-8.
Brain Injury. 1996 Jan;10(1):55-63.
Convuls Ther. 1995 Mar;11(1):45-50
J Neurosurgery. 1989 Jun;70(6):879-83.
Neurosurgery. 1989 Mar;24(3):392-7.
Apathy syndrome is a significant clinical problem in patients with neuropsychiatric sequalae after acquired brain injury (ABI). It may coexist with depression and impact the clinical picture and treatment outcomes. Results of treatment of apathy syndrome in this small sample of patients (N=19) with ABI are presented. Dopaminergic agonists were used for treatment and the response was measured with Apathy Evaluation Scale (AES) and Beck Depression Inventory (BDI). All of the 19 patients responded to treatment and improvement in apathy scores was statistically significant (p.004) and no significant change was noted in depression (p.22). (submitted for publication]
Methods: Charts of six children and adolscents who were consecutively admitted to a long-term care facility were reviewed for clinical outcomes including seclusion and restraints incidents prior to and during clozapine treatment, and a representative case-history is presented.
Results: Clinically significant improvements were noted in social interactions, decreases were noted in the number of violent episodes, homicidal and suicidal thoughts. The global assessment of functioning scores improved significantly. There was significant weight gain.
Conclusions: These cases illustrate the benefits of clozapine in refractory childhood onset schizophrenia, similar to outcomes described in adults. Even though open data llimts conclusions from this study, it is pertinent that there was a clinically significant improvement with aggressive behaviors. This may be particularly important from the point of view of improved morale for patients, their families, and treating staff.
(submitted for publication]
Traumatic brain injury primarily affects cognitive abilities, such as short-term memory, attention, concentration, and learning new materials. Children have difficulty returning to their previous level of functioning at school. They may become hyperactive, irritable, aggressive and show other changes in their personality. They may show signs of ADHD with lack of concentration, easy distractibility, and difficulty to grasp new concepts. Their grades could start to decline. They may show significant mood swings ranging from rage outbursts to depression. These changes in a young child’s life lead to frustrations for parents, teachers, and the child himself. The children start to withdraw and develop problems with self-esteem and self-confidence. They may even become apathetic.
Other symptoms of head injury may include physical, emotional, behavioral, and neurological changes. These may include – headache, sleep problems, chronic pain, seizures, anxiety, depression, nightmares, disruptive behaviors, etc. Anxiety syndromes manifest as fearfulness, worry, and persistent tension. Depression is not easy to recognize in children and it can be very disabling. Unlike most injuries, such as a broken leg or a third-degree burn, the evidence of the trauma is often intangible, and the symptoms can be puzzling and unclear. Such an experience oftentimes is very stressful for the patient, his family, and his doctor.
Children are especially at high risk for head injury because of involvement in sports, bike riding, skating, swimming, vacation travel etc., more so in summer months. The use of a helmet, which for the state of Pennsylvania is a law for all children under the age of 12, is essential when riding a bike. Making sure the children are wearing a seatbelt and preferably ride in the back seat of an automobile. The effects of a head injury can be life long.
Most children show good recovery from a mild head injury over one to three months while the symptoms of severe head injuries usually persist. Anyone with symptoms beyond three months should seek further evaluation and treatments from specialists such as neurologists, child psychiatrists, or neuro- psychiatrists. Educating the family, teachers, and the patient is very important. Depression, anxiety, irritability, and problems with self-esteem and self-confidence can be treated with education, counseling, and medications. There are many organizations that provide support and information for patients and their families about brain injury. (Brain Injury Association at 703-236-6000; www.biausa.org )
Ravi Kant, MD
Head Injury Clinic
Pittsburgh, PA 15017
More than two million closed head injuries (CHI) occur in this country in a year.Earlier studies had estimated the incidence rate of about 220/100,000 persons (1). Recent study by Sosin et al. (1996) estimates the incidence of mild to moderate head injury to be about 610/100,000 persons per year in a non-institutionalized population (2).This is almost three times what the earlier studieshave indicated. The earlier studies were based on retrospective reviews of hospital records. The highest rate ofCHI is for males at all ages (except 75 years and older) and peak rates are noted for males aged 15 - 24,rate for males being twice as high as that for females. The ratio of males to females decreases to nearly 1:1 after age 75 because mostof head injuries occur due to falls. The most common causes of CHI are motor vehicle accidents (MVA) (42%) and falls (20%).In almost 50% of head injury cases, intoxication is a contributing factor (1). About 85% ofCHIs are classified as mild. The rate of injury is inversely correlated with family income, the highest rates being in the lowest income group and were more often caused by MVA or assaults (3).
Mechanism of injury and pathophysiology
CHI causes trauma to the muscles, bones, ligaments, blood vessels, nerves in the neck and head in addition to an injury to the brain. All CHIs do not necessarily involve trauma to the brain. There are multiple physical forces involved, in addition to the neuro-chemical changes in the brain, which determine the severity of injury. The physical forces impacting on the brain include direct trauma to brain, coup-counter coup injury, rotational forces, pressure gradients, stretching of brain stem and spinal cord, changes in intra-cranial pressure, cerebral edema, contusions, and hemorrhages.CHI causes shear strain and diffuse axonal injury to the brain and hence, producing "multi-system" neurobehavioral symptoms. Frontal lobes are the most common site of injury (4) and temporal lobes are the next common site. Cerebral contusions and hematomas can be seen even after mild head injury. Severity of head injury is usually determined by Glasgow Coma Scalescore (GCS) (5) (Mild - GCS score of 13 - 15; Moderate - GCS score of 9 - 12, and Severe - GCS score of8).
Common post concussion syndrome symptoms are physical, emotional, and cognitive(see table 1). Headache, sleep disturbance, dizziness, irritability, anxiety, cognitive slowing, difficulty in handling information, and short term memory problems (manifesting as forgetfulness, misplacing things, difficulty in learning new materials etc.) are commonly seen. Most of these symptoms abate in a few weeks to three months. In about 50% of patients, a few symptoms may persist beyond six months and about 10 -20% patients may go on having Persistent Post-Concussion Syndrome ( PPCS) i.e. two or more symptoms persisting beyond one year (6). These patients need comprehensive neuro-psychiatric evaluation and treatment focussed on head injury and its associated symptoms for proper rehabilitation and return to work.
Following are some of the common neuropsychiatricconditions seen after closed head injury.
Headache is the most common complaint after CHI. It is reported to have a greater frequency and duration after mild CHI compared to moderate or severe head injury. Cause for post- traumatic headaches is multi-factorial. These factors include soft tissue injury, neuroma formations, tissue scarring, entrapment of nerves in bony or fibro-muscular tissues, direct injury to nerves such as greater occipital nerves, vascular, and myofacial injuries. Post-traumatic headachesare of multiple types, and patients usually have more than one type. Essentially all types of headaches could be seen after CHI.Following types of headaches are commonly seen after CHI-migraine, tension-type, occipital neuralgia, cervicogenic, basilar artery migraine, and dysesthesia due to posterior cervical sympathetic nerve injury. Detailed history should be taken to evaluate the headaches and look for psychological and social factors, including legal issues. Treatments should be based on the type of headache and also eliminating or minimizing the exacerbating factors.Psychological and legal issues should be addressed as needed. Avoid use of narcotics and other medications with addicting potentials.
Depression is reported in 25 to 50% of patients after head injury (7).It is one of the most disabling conditions after head injury that the patients experience. Depression negatively affectsthe family and social relationships. It also have impact on cognitive functioning and ultimately delays return to premorbid level of funtioning. Depressed patients cannot effectively participate in rehabilitation services. There is some controversy about the underlying cause- whether it is psychogenic, biological, or both. The frontal lobes are the most common site of injury to the brain after a CHI (4) and frontal lobe dysfunction is commonly seen in patients with endogenous depression. Other factors contributing to depression may be physical, social, and cognitive changes following injury which include headaches, insomnia, inability to work, dependency, social withdrawal, discouragement, and demoralization along with cognitive difficulties described above. Because of all of these changes going on concurrently, it is difficult to separate biological from psychogenic factors. There may be a difference in the degree of contribution of these factors in each patient and at different stages of recovery.
Anti-depressants and other treatment modalities can be used for treatment of depression including electroconvulsive therapy (ECT). ECT has been effective in treating depression after head injury. We have successfully treated 13 such patients with ECT (8,9). In some cases, depression becomes chronic, refractory, and is difficult to treat. Careful attention should be paid in selecting an anti-depressant because of their cognitive side effects. Anti-cholinergic side effects of the tricyclic anti-depressants (cause dry mouth, constipation etc.)can impair memory, concentration, and attention span.
Anxiety is another common condition seen after head injury.There are no prospective studies to estimate the incidence of anxiety syndromes, but it has been reported to occur in 10 to 50% of patients.Generalized anxiety manifests as fearfulness, worry, persistent tension, and intense feeling of anxiety.Obsessive-compulsive behaviors have been seen, at times manifesting as a full-blown syndrome of an obsessive-compulsive disorder (10). At times, a person may have a catastrophic reaction to an acute situation. Post traumatic stress disorder (PTSD) is also seen in some patients, especially those who did not lose consciousness.PTSD in itself can lead to symptoms of depression, cognitive deficits, behavior changes such as anger and irritability, and somatic symptoms of sleep and appetite disturbance. Treatment usually involves educating the patient and the family, providing a supportive environment, and at times medication.Anti-anxiety medications should be selected very carefullybecause of their potential of dependance and worsening of cognitive deficits.
Personality changes are one of the most significant problems seen after head injury. Family members frequently complain that the patient is a totally changed person after the injury. Sometimes this is an exacerbation of a person’s pre-morbid personality traits. Some patients become aggressive and disinhibited on one extreme while others may become apathetic and lack initiative on the other extreme. Apathetic patients look depressed and hence mistakenly treated with antidepressants. We conducted a study to estimate the incidence of apathy after CHI. We found that apathy occurs in about 11% of patients seeking treatment for neuro-psychiatric problems after head injury (11). At times patients become very labile and paranoid, and some patients develop childish behavior. These extreme changes are seen after moderate to sever CHI. Personality changes can also be secondary to temporal or frontal lobe seizures. Some of these symptoms can be treated by behavior modification and medications, while for others, patient and family education and environmental changes are needed.
Cognitive changes involve problems with short-term memory, attention, concentration, information processing, difficulty making decisions, and executive functioning. Long term memory usually remains intact after mild to moderate CHI. Patients are forgetful about simple things such as telephone numbers, names, faces, and daily tasks. They get confused in over stimulating environments such as malls, large grocery stores, and large crowds. Patients have difficulty learning new materials. This in itself causes a lot of frustration, anger, and other emotional difficulties. At times, it is difficult to carry out simple tasks because of executive dysfunction. This leads to despondency, self-doubt, and frustration.Treatment of underlying conditions such as depression, anxiety, insomnia, chronic pain etc. improves the cognitive status. Some patients may need cognitive retraining and/or medication interventions for improving their cognitive status.
Perceptual changes are commonly seen in the early phase of brain injury, especially in the subacute phase.However, psychotic symptoms can also happen a few months to many years after the injury. It can manifest as hallucinations, delusions, paranoia, or any other perceptual disturbances.Sometimes psychotic symptoms are secondary to temporal lobe seizures. Overall, incidence of perceptual disturbances is very low, except for in the acute and sub-acute phase.
Some unusual or late sequelae ofclosed head injury include anosmia, chronic pain syndrome, seizures, endocrine disorders due to injury to hypothalamic - pituitary axis,dystonia,hydrocephalus, cortical atrophy, aneurysms, sleep-wake cycle alteration(12), movement disorders including hemiballismus (13),and somatization disorders. Clinicians should be aware of these conditions and should not label the patient as malingering or having conversion reaction without proper evaluation.
Wait and see approach should be employed in the first few weeks after injury except for conservative symptomatic treatments for pain and insomnia. Patients with continued disabling symptoms of cognitive, behavioral, or emotional changes four weeks or so after injury or if symptoms are getting worse, should be referred for comprehensive neuro-psychiatric evaluation. It is very important to establish the baseline severity of symptoms early and follow the progression of symptoms. It is especially important in patients with mild head injury because their primary disability usually arises from neuro-psychiatric symptoms.
Evaluation should be done by someone who is familiar with and have experience in evaluating and treating patients with head injuries. Comprehensive evaluations may include neuro-psychiatric evaluation, neuro-psychological testing, neuro-imaging such as MRI and/or SPECT scan of brain, EEG, and neuro-rehabilitation evaluation. Also, assess for individual and/or familytherapy, cognitive retraining, chronic pain program, and vocational retraining.
Treatment process involves educating the patient and his/her family members, on-going evaluations, and comprehensive treatment strategies which may involve identifying and treatingphysical, emotional, cognitive, and neurological symptoms. Appropriate referrals to neuro-psychology, rehabilitation, and neurology should be considered. Careful selection of medications is very important as some of the commonly used medications can have significant negative effects on the motor and/or cognitive recovery process. Outcome measures should be utilized to measure the baseline severity of symptoms, progression, and response to treatments.
Following factors favor good outcome - young age, no past CHIs, no history of substance abuse, good family support, married, no past history of disabilities, stable and high skill job, and above average intellectual functioning.
1.Krause JF, Sorenson SB. Epidemiology. In: Silver JM, Yudofsky SC, Hales RE, eds. Neuropsychiatry of Traumatic Brain Injury. Washington, DC: American Psychiatric Press Inc. 1994:3‑41.
2.Sosin DM, Sniezek J, Thurman DJ. Incidence of mild to moderate brain injury in the United States, 1991. Brain Injury. 1996;10:47‑54.
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4.Mattson AJ, Levin HS. Frontal Lobe dysfunction following closed head injury. Journal of Nervous and Mental Disease. 1990;178:282‑91.
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6.Alexander MP. Mild traumatic brain injury: pathophysiology, natural history, and clinical management. Neurology. 1995;45:1253‑60.
7.Jorge RE, Robinson RG, Starkstein SE, et. al. Comparison between acute and delayed onset depression following traumatic brain injury. J Neuropsychiatry Clin Neurosci. 1993;5:43‑9.
8.Kant R, Bogyi A, Carosella N, Fishman E, Coffey CE. ECT as a therapeutic option in severe head injury. Convulsive Therapy. 1995;11:45‑50.
9.Kant R, Bogyi A, Coffey CE. ECT after traumatic brain injury. Convulsive Therapy. 1995;11:[Abstract]
10.Kant R, Seemiller L, Duffy J.D. Obsessive compulsive disorder after closed head injury: Review of literature and report of four cases. Brain Injury. 1996;10:55‑63.
11.Kant R, Duffy J, Pivovarnik A. Prevalence of apathy following closed head injury. Unpublished data. 1996.
12.Bachman D. L. The diagnosis and management of common neurologic sequelae of closed head injury. J Head Trauma Rehabil.. 1992;7(2):50-59.
13.Kant R, Zeiler D. Hemiballismus following closed head injury ‑ case report. Brain Injury. 1996;10:155‑8.
Table 1Common Post-Concussion Syndrome Symptoms
3. Sleep disturbance
4. Diplopia and blurring of vision
5. Light and sound sensitivity
6. Neck pain
7. Tinnitus (ringing in ears)
12. Mood lability
13. Slowed thinking
14. Short-term memory problems
15. Impaired concentration and attention span
16. Periods of confusion
17. Difficulty learning new materi
Brain Injury, 1998, vol. 12, No. 1, 87-92.
Psychiatric Annals 27:1/January 1997
AES scores improved after treatment for twelve weeks with methylphenidate in ten patients (p.004). Similar change in AES - I scores was noted (p.01). BDI scores did not change (p.227). These gains were maintained on long term treatment (Ave. 11 months). We believe apathy is a frequent symptom after CHI and it responds well to dopaminergic agents. It appears to be an independent entity, but may co-exist with depression.
(Submitted for publication)